How To Heal Injuries

Everyone gets hurt. Not everyone heals at the same rate, however—not because of inherent differences in genetic makeup and physiology but rather because of differences in behavior (as well as the type and severity of the injury). Two of the most common misconceptions about healing relate to which behaviors actually promote it and what exactly constitutes a reasonable time course over which it should occur. Every injury, of course, is unique. What follows is meant to be neither comprehensive nor exhaustive but rather to introduce some general guidelines for healing injuries—none of which are intended to substitute for your own doctor’s advice regarding any specific injury from which you may be suffering.

GENERAL PRINCIPLES

Injuries to the musculoskeletal system come in two basic types: acute traumatic and chronic overuse. The tissues predominantly involved include bones, ligaments, tendons, muscles, and bursae, though which bears the greatest brunt of injury in any particular circumstance will, of course, vary. Common locations for these types of injuries include the back, neck, shoulders, knees, ankles, and feet.

Treatments differ slightly depending on the location of the injury and which specific tissue type suffers the greatest impact. In general, for acute musculoskeletal traumatic injury (excluding broken bones) we try to make the injury “NICER”—that is, we use NSAIDs, Ice, Compression, Elevation, and Rest, all of which are designed to reduce the early phase of inflammation present in acute traumatic injuries. While making an injury “NICER” may or may not speed healing (see below), it almost certainly will improve pain.

In chronic overuse injuries, however, inflammation may not actually play a significant role, which may explain why NSAIDs in that setting, while often useful for reducing pain, are often unhelpful in actually healing the injury itself. When tendons injured chronically from overuse, for example, are viewed under the microscope we see very little inflammation. As a result, the term “tendinopathy” is now preferred over “tendonitis” to suggest the pain may be coming from microtears or some other mechanism besides inflammation.

The main therapeutic treatment I apply to most musculoskeletal injuries, whether acute or chronic, is the simplest: rest. Whenever you develop force across an injured tissue, you’re almost certainly retarding its healing. Some musculoskeletal injuries can take literally years to heal completely (I once injured my shoulder bench pressing and had to wait three years before I could bench press again without pain). Sometimes rest can only be enforced by applying a splint (such as to the wrist in order to prevent force being delivered across the elbow during wrist extension in tennis elbow). Patients—especially active, athletic ones—typically hate hearing they need to stop using the injured tissue even for a little while. But it’s far better to stop using it—even for months, if need be—than suffer an injury that takes years to heal. How do you know you’re adequately resting an injury? It’s easy. Don’t do anything that causes it to hurt…

…with one possible exception. Studies of patients with Achilles’ tendinopathy have shown improved healing from eccentric exercise. Eccentric exercise involves lengthening a muscle against resistance (in other words, a controlled lowering of a weight) compared to shortening a muscle against resistance (as when you curl a dumbbell with your bicep to your chin, for example). Some degree of discomfort during the eccentric training of these patients’ Achilles’ tendons was actually associated with faster recovery times. Studies showing the benefit of eccentric exercise for other types of tendinopathies are beginning to appear as well, suggesting its prudent use for other tendon injuries seems reasonable. Be careful to reserve this modality for chronic overuse injuries, however, in which acute inflammation is less likely to be playing a role as the cause of pain and under the supervision of your doctor and/or physical therapist.

Physical therapy, by the way, consisting of stretching and strengthening exercises is usually quite helpful at improving pain and joint range of motion if appropriately timed and done on a regular basis. Though modalities such as ultrasound and iontophoresis have been shown to improve swelling and inflammation at a microscopic level, little if any evidence exists that they actually speed healing.

NSAIDs

NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil, Motrin) have played a role in treating musculoskeletal injuries for decades, but data proving their effectiveness in speeding healing (compared to providing pain relief) is surprisingly scant. In fact, even though some studies suggest their use results in a speedier return to normal strength in the short term, their use may actually retard healing in the long term.

NSAIDs provide two independent effects: pain relief and reduction in inflammation. However, these two benefits occur at different dosages. For example, ibuprofen can provide pain relief at just 400 mg/day but only at 1800 mg/day does it provide an anti-inflammatory effect. Pain from a musculoskeletal injury may or may not be caused by inflammation (see above), but NSAIDs can provide pain relief from injury without reducing inflammation, or in the absence of inflammation, via reduction of prostaglandin production in the central and peripheral nervous systems. However, such mechanisms almost certainly don’t speed healing.

Many people don’t know that NSAIDs come in different classes. NSAIDs from one class may be of tremendous benefit in controlling your pain but not help someone else at all and vice versa. In general, if one NSAID isn’t working to reduce your pain, switching to another one from another class might help. Check with your doctor to identify which NSAIDs come from classes other than the one you’re currently taking.

In general, after an acute musculoskeletal injury, I will recommend NSAIDs at anti-inflammatory level doses for brief periods on a scheduled basis (1-2 weeks at most) and then on an as-needed basis for pain control thereafter.

SPECIFIC COMMON INJURIES

What follows is intended as a broad discussion of the most common types of musculoskeletal injuries. You should take care not to conclude that any pain you may be experiencing could only be coming from the diagnoses discussed below, nor should you use this discussion as confirmation of a diagnosis you may be considering yourself without consulting your own doctor. Having said that, once a clear diagnosis is made, you may find the principles below helpful:

The back. Literally 90% of all back pain has a benign course and is due to acute or chronic musculoskeletal strain of one of the connective tissue elements of the spine (often as a result of the smallest of actions, like leaning forward to pick up the salt, or sneezing, sometimes preceded by heavy lifting, sometimes not). The remaining causes include an assortment of age-dependent diagnoses like herniated disks, spinal stenosis, and, rarely, metastatic cancer. When people acutely injure their backs, 80-90% have near complete resolution within 12 weeks (which means, unfortunately, 10-20% take longer and sometimes go on to develop chronic low back pain). While many advocate immediate physical therapy, I don’t. In my experience, during the early phase of back injury, physical therapy is as likely to worsen the pain as it is to improve it. I recommend avoiding heavy lifting (or any lifting if possible), sleeping flat on your back with a pillow under your knees to keep them at about 10-15 degree angle (it’s amazing how easy it is to re-injure your back—or neck, for that matter—during sleep. If you wake up feeling like your pain is back to square one, it’s probably because you slept in a position that put strain on the injured tissue), avoiding ice (unlike musculoskeletal injuries in other areas of the body, injured tissue in the back is usually too deep for the cold to reach; it often just induces muscle spasm which increases pain), and using heat immediately to reduce muscle spasm. Pain will often refer down one or both legs from back strain, almost always stopping above the knee. This is entirely different from radicular pain, which usually goes below the knee and may suggest a herniated disk. Even if you have a herniated disk, however, unless you have uncontrollable pain or muscle weakness, the treatment is the same as for musculoskeletal back strain: rest. Enforced bed rest, however, has been shown to actually retard recovery from acute musculoskeletal back pain. If you’re in too much pain to get out of bed, by all means, stay there until you’re not—but otherwise, don’t put yourself to bed.

The shoulder. Though many elements in the shoulder (the joint with the widest range of motion and therefore greatest susceptibility to injury) are at risk for injury, the two most common injuries are usually, though not exclusively, overuse injuries: subacromial bursitis and rotator cuff tendonitis. Though patients often have difficulty telling these two injuries apart (symptoms of both include pain when abducting the arm) an experienced physician can easily distinguish them on physical exam. Subacromial bursitis is usually amenable to a cortisone injection plus physical therapy, while rotator cuff tendonitis is usually treated with physical therapy alone (you can’t and don’t want to inject a tendon).

The hip. There are, in general, 5 causes of hip pain, diagnosable by single physical exam maneuver: the examiner simply asks the patient to point with their index finger to the exact location of pain. Depending on where they point, the cause of hip pain will be: quadraceps tendonopathy, trochanteric bursitis, pain localized to the hip joint itself (usually from arthritis), sacroiliitis, or low back pain. Sometimes a leg-length discrepancy causes hip pain and can easily be solved by wearing a heel lift. Trochanteric bursitis can usually be cured with a single cortisone shot. The other types of injuries usually require NSAIDs and/or physical therapy.

The heel. The most common cause of heel pain in adults is plantar fasciitis. The most common presentation involves heel pain that’s worse with the first step of the morning (getting out of bed) but which improves modestly as the patient walks on it early in the day and then gets bad again near the end of the day. Flexible heel inserts combined with NSAIDs, a night splint, and a reduction of walking help. In recalcitrant cases, a steroid injection into the sole of the foot may be necessary (and really hurts).

CONCLUSION

The preceding discussion was intended only to scratch the surface of the more common musculoskeletal injuries and to describe the treatments that have the greatest weight of evidence for their effectiveness, recognizing there still remains more we don’t know than we do about how to heal musculoskeletal injuries. In general, we can consider the human body to be mostly endowed with the mechanisms necessary to heal the injuries described above and that much—though by no means all—of what we need to do is simply get out of the body’s way and take care not to do things that actively work against it’s efforts to heal itself (this excludes, of course, circumstances in which surgery is required, which was outside the scope of this post). Some chronic injuries, however, resist even the best attempts to heal them, making prevention the best strategy for dealing with them. Thus, if there’s any one principle to take away from this discussion it would be this: whenever you injure yourself, rest, rest, rest.

In the case of plantar fasciitis, I found it helpful to stretch the affected heel each morning for 15-20 seconds before stepping out of bed or after sitting for awhile during the day. Over a period of time the discomfort diminished until I have no residual pain at all. To stretch the muscle, lay on your back in bed and raise the foot as high as you can. Looking at your foot, point the toe toward your head and hold it for 15-20 seconds. It’s important to do this every time you’ve been resting in bed or in a chair for some time because during rest the muscle contracts and shortens. By stepping on it before stretching it you reinjure the muscle each time. Some find it helpful to hold the ends of a hand towel in both hands, loop it under the toes, and use it to pull the toes toward your head thereby stretching the muscle.

Can you comment on coping with the “unhealable” like fibromyalgia and other central pain syndromes.

A nurse with FMS.

Susan: Fibromyalgia and other central nervous system pain syndromes are awful and difficult to treat conditions (as you’re undoubtedly aware). I have a score of patients with fibromyalgia and a handful with central nervous system pain syndromes as a result of cerebrospinal fluid leak (both spontaneous and as a result of trauma) who underwent brain surgery and shunting and now are left with truly horrible, intractable pain. To do either of these subjects justice would require more than even a post on a blog could provide, but I’d like to make the following comments.

Anti-depressants are currently considered the most effective therapy for fibromyalgia (not because the cause of fibromyalgia is considered to be caused by depression—it is a very real disorder whose cause we just don’t yet understand). In 2008, the FDA approved three drugs for the treatment of fibromyalgia based on studies proving their effectiveness: duloxetine, milnacipran, and pregabalin (an anti-seizure medication), though many other medications are used off label with good results as well. NSAIDs have been shown NOT to be helpful as inflammation in muscle tissue is clearly not the cause of pain in fibromyalgia. The severity of fibromyalgia symptoms vary from individual to individual: some have mild symptoms they tolerate without much, if any, interference in their normal daily activities while others are completely disabled by their disease and can’t work. Aerobic exercise has also been shown to improve pain and pain tolerance in the long run (even if in the short run it hurts more for patients with fibromyalgia to initiate exercise programs). Mindfulness meditation exercises have also been shown in trials to help reduce the pain of fibromyalgia.

My personal opinion is that, while many of these treatments can provide some benefit, we’ve yet to fully understand what’s really going on in the central nervous system to cause this disorder and therefore haven’t really been able to identify therapies that directly target fibromyalgia’s true cause. There is clearly a psychological/emotional influence on the severity of symptoms, but I don’t believe psychological disturbances of any kind actually CAUSE it. A lot of research is going on to better understand fibromyalgia so I don’t think I’m being too optimistic when I say a better understanding—which will invariably be followed by better treatments—is around the corner. Support from other patients suffering from fibromyalgia and an understanding physician are, in my view, indispensable components of a successful treatment program. I hope you find these (very) brief comments helpful.

Excellent perspective on a problem that all encounter throughout their lives. Personally, I have experienced many injuries, from minor to serious, in a very active lifetime and using rest efficiently for the specific situation has always been a big part of the recovery. I would add that there are some things that can be done to expedite the healing besides rest; optimal nutrition, complete hydration, adequate sleep and passive movement, if possible, to maintain range of motion and increase circulation.

Thanks so much for this info. I have been struggling with a re-injured lower back this summer (just when I had all this time off to get in better shape), and your concise posting has not only informed but reassured me. Patience, patience!

I am a UK physiotherapist—interested in pain management/physiology/behaviour.

I thought your account was very useful. Not many physicians seem to take note of the information on the lack of inflammation and still use the NSAID/injection approach. I think a big issue with ongoing pain from injuries is the effect of co/contraction inefficient motor patterns—things like the body scanning/’bodyawareness’ are useful here. Regaining motor activity/proprioception is not always automatic in the car and computer era (maybe this general societal ‘ischemia’ is an issue especially in many insidious more ‘centralised’ pain syndromes?

A huge issue with back pain is a lack of physiological understanding on how long structures such as poorly innervated and vascularised discs take to heal—this may then lead to secondary pain behaviour or rush to fix the tissue with surgery?

There is a real move in physiotherapy to understand pain biology and I think this is a really positive step!

Alex:
I have added your article to my favorites for future reference when needed for healing. I would like to note that I always thought that application of heat would help a painful back. That was until I had lower back pain and one night slept with a heat wrap; in the morning I could hardly get out of bed. I had to walk around stiff all day. I was advised to use cold packs 15 minutes at a time every hour. It was amazing the first 15 minutes gave me great relief and the repeating continued to help. I know this is only one case; however, because of that experience I felt it important to disagree with your advice to shy away for cold applications and use heat for lower back pain.

Otherwise, I thank you for all the great advice your article delivers.

John: Thanks for sharing your experience. Just goes to show you, in biology there are always exceptions!

Ten months ago, I felt a sudden sharp pain in my shoulder. It didn’t get better; rather it got worse. I could no longer swim using that arm and quit the pool club. Over time, it got worse. I had cortisone, physical therapy, even massages. An ultrasound showed torn tendons. I stopped trying to “fix” it, devised ways of doing things without the use of the right arm. Three months after a second shot of cortisone’s immediate effects wore off, something happened. The physiotherapist’s prescribed exercises I was doing seemed to be more effective, and it started healing by itself. (The exercises were different variations of just lifting the arm till it hurt and trying a bit more each day). I found I could once more lift my arm enough for me to swim again, with a slight adjustment in style. I have once again joined a pool and tomorrow will be the first time in 10 months that I will swim. I am excited. I hope I am not doing the wrong thing.

After age 60 I experienced muscle pulls, and tendon strains that would not heal. Worse yet I noticed the stiff joints that “old” people complain about. I supposed the time had come to supplement my adrenal hormones with DHEA, the precursor of adrenal steroid hormones estrogen, testosterone, cortisone, and aldosterone. DHEA is not only a precursor but a reservoir for these hormones. DHEA is manufactured on a diurnal cycle between 4AM and 10AM. The day’s need for these hormones is produced from the DHEA reservoir as required. I now take 50 mg of DHEA at 10AM. I don’t notice as much stiffness, and my tendons and muscles repair more quickly.

Rest is problematic because the body needs activity to maintain health. Regarding musculoskeletal health, activity is necessary for both local strength and resistance to injury as well as systemic conditions.

That is why many athletes have a problem with the advice “rest”: They know, both in their head and also according to how it feels, that extended rest (e.g. to allow injury to heal) causes atrophy, loss of bone mineral density and strength, metabolic dysfunction, and many many other negative results. Extended rest makes one weak and ill, and it feels BAD—plus, it makes it even harder to regain former condition.

That doesn’t refute the need for rest to heal injuries; it just explains why some people (genuinely athletic types, as opposed to socialized-athletic types such as organized sports participants) have a problem with rest.

[…] For example, I personally had very good results with slow eccentric training to heal my own tendinosis in my shoulder. Before trying this therapy, be careful and speak to your doctor. In addition, check out this article by Dr. Alex Lickerman on How to Heal Injuries. […]

Adrenal fatigue gal: Not specifically. In general, pace yourself. Don’t surpass what you know to be your exercise tolerance and risk an exacerbation of your chronic fatigue. The glass is always half full.

This was very helpful advice. I am new to your blog, and from what I have read so far, I am very inspired.

I have been dealing with PTTD for the last year and a half, and I think what helped most was a good bit of rest and lot of (reluctant) stretching. I still find the discipline required for daily stretching as a constant challenge. Often the limitations I face in my daily activities depress me. I was hoping to start walking/biking again this year, but I can’t seem to figure out way to begin without risking injury to my ankles. Do you have any ideas for how I can watch for signs of trouble? Thanks.

TD: Sorry, I don’t know what PTTD is. Email me directly through my Contact page and I’ll try to help you as best I can.

Active Release Therapy (ART) clinic claim they have a 80-90% success rate with tennis elbow within 5-6 treatments. After reading your article that it can take years for these types of injuries to heal, is this just BS? They seem to have their theories (as everyone does) as to why it works. Thanks!

Robert: Not many good studies on ART. Not likely to be of harm in the right patients but I’m withholding judgment about its efficacy at this point due to insufficient data. Of note, the injuries that ART is supposedly good for are not necessarily acute muculoskeletal strains but rather chronic pain theoretically due to the presence of scar tissue.

As a podiatrist I can tell you that we see many patients in clinic with plantar fasciitis. There are many different treatment options; however rest is vital. Stopping all activity immediately is the first step to taking proper rest; resisting the urge to return to your former level of activity before the pain has heeled is the second step to taking proper rest. Insisting that a person experiencing heel pain rest more often is a precarious situation, because reducing pressure on the foot is necessary but reducing activity levels can also lead to muscle atrophy which in some cases is part of the problem to begin with.

Stretching tight and/or or inflexible calf muscles is one of the major causes of heel pain. Aside from putting more strain on the foot muscles in general, tight caves can cause the foot to pronate inwards and when this happens a painful case of plantar fascia—and the resulting heel pain—is not usually very far behind. Start by warming up the calf muscles with a few shallow heel dips on a low stair before going deeper into the stretch; if you pull too hard on a cold muscle it can cause an injury or aggravate an issue that is already present. Many people who suffer from constant heel pain have found relief in an increased flexibility in the calf muscles.

Properly applied athletic tape can support the planter fascia and reduce the tension load it bears. There are many qualified physiotherapists who have great experience and success in alleviating heel pain through this kind of treatment.

Having proper arch support/orthotic is one of the top recommendations of us podiatrists, and it many, many sufferers of heel pain have found relief by using orthotic devices.